Palisade neutrophilic and granulomatous dermatitis L95.1

Rare, chronic reactive, papular or plaque-type extremity dermatitis, which is considered a skin disease commonly associated with rheumatoid arthritis. However, palisade-shaped neutrophil and granulomatous dermatitis also occurs in the wake of other systemic diseases(systemic lupus erythematosus, sarcoidosis, Behçet's disease, spondylarthritis, borreliosis and lymphoproliferative diseases). Furthermore, it is used as a UAW in various diseases. It is also described as an adverse drug reaction.

Very rare. Individual case descriptions. No gender accentuation

Middle to advanced age; rarely childhood.

Palms, back of the hand, fingers, elbows, more rarely lower extremity, face or capillitium.

Blurred, asymptomatic, mostly disseminated, chronically persistent red-livid papules and plaques; more rarely nodules.

Nodular infiltrates of lymphocytes, macrophages, eosinophilic and neutrophilic granulocytes are found throughout the dermis, extending to the border of the subcutis; often accompanied by nuclear dust as a sign of leukocytoclasia. Only isolated multinuclear giant cells. The infiltrates are often grouped around flat degenerated collagen. Furthermore, small and medium-sized vessels with fibrinoid swollen vessel walls are frequently detected.

Erythema elevatum diutinum, interstitial granulomatous dermatitis, granulomatosis disciformis chronica et progressiva

Treatment of the underlying disease

The terms "palisaded neutrophilic and granulomatous dermatitis," "interstitial granulomatous dermatitis," and "interstitial granulomatous drug reaction," the possible clinical and histological overlap of the disease patterns cause significant differential diagnostic problems. The reports are generally based on individual case descriptions. The assumption is an unspecific "reaction cutanèe" to an underlying systemic disease or cofactorially to an additional therapy regime. To what extent these are "entities" may be doubted, particularly since a comparative evaluation of the older literature (for example the erythema elevatum diutinum or the granulomatosis disciformis et progressiva which also belong to the group of reactive granulomatous dermatitis) is missing. Rosenbach et al. recommend the non-evaluative summary diagnosis for this group of diseases:"reactive granulomatous dermatitis".

The 73-year-old patient, who has been suffering from rheumatoid arthritis for about 5 years. She has been treated for years with methotrexate (15mg/week s.c.) and adalimumab. Otherwise occasionally non-steroidal anti-inflammatory drugs. Skin changes resistant to treatment have existed on both hands for years

Clinically, multiple, disseminated red-livid, asymptomatic surface-smooth papule plaques were found in a symmetrical arrangement on palmar as well as on both backs of the hands (here reinforced above the metacarpophalangeal joints). The plaques were up to 2.0 cm in size.

Laboratory: rheumatoid factor: within normal range; anti-CCP-AK: moderately elevated. Inflammation parameters significantly increased.

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